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Intracranial Haemorrhage

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Overview

An intracranial haemorrhage (ICH) describes bleeding within the skull. ICHs can be divided into:

  • Extra-axial ICH – outside the brain parenchyma:
    • Extradural haematoma
    • Subdural haematoma
    • Subarachnoid haemorrhage
  • Intra-axial ICH – within the brain parenchyma

Trauma is the most common cause of ICH. ICH is a medical emergency as the build-up of blood can lead to raised intracranial pressure which can lead to brain damage and herniation.

Each type of ICH has different aetiologies and management steps, which are discussed below.

Extradural Haematoma

Overview

Also known as an epidural haematoma, an extradural haematoma (EDH) describes a collection of blood between the skull and the dura mater.

It is most often due to trauma to the pterion of the skull in the temporal region leading to rupture of the middle meningeal artery.

  • The pterion is thinner and weaker and hence, more susceptible to damage

Presentation

Patients classically lose consciousness initially then briefly regain consciousness (known as the lucid interval), and then lose it again. This happens as the haematoma expands and presses on the brain.

As further haemorrhaging occurs, the following may be seen:

Patients with a traumatic EDH may also have a traumatic cervical spine injury.

Differential diagnoses

Acute subdural haematoma

  • Usually due to high-impact trauma and there are associated brain injuries
  • CT shows a hyperdense (bright) crescenteric collection that is not limited by suture lines
  • Large subdural haematomas may cause midline shifts/herniation

Chronic subdural haematoma

  • Usually seen in patients with fragile bridging veins: elderly people, alcohol abuse, shaken baby syndrome
  • CT shows a hypodense (dark) crescenteric collection that is not limited by suture lines
  • Initially they may be small and not cause symptoms, but subdural haematomas may cause midline shifts/herniation

Subarachnoid haemorrhage

  • Sudden-onset “thunderclap” headache described as the worst headache they have ever had
  • They may have symptoms of meningism – neck stiffness/photophobia

Intraventricular haemorrhage

  • Relatively rare in adults, associated with severe head injuries
  • More common in premature neonates
  • Obstructive hydrocephalus symptoms may emerge and signs of raised intracranial pressure 
  • CT shows hyperdense collections in the ventricles, most commonly in the lateral ventricles

Investigations

  • CT head – initial test of choice:
    • Shows a biconvex (lentiform), hyperdense collection which is limited by the suture lines of the skull
  • X-ray of the cervical spine:
    • Patients with an EDH may have an associated traumatic cervical spine injury, CT may need to also be considered
  • FBC:
  • U&Es:
    • As a baseline
  • Coagulation screens:

Never perform a lumbar puncture in a patient who is suspected to have raised intracranial pressure without specialist supervision – this can cause cerebral herniation.

Management

  • 1st-line: ABCDE approach and full trauma assessment
  • If no neurological deficit: observe with regular imaging
  • If neurological deficit present: burr holes or craniotomy may be needed

Complications

Prognosis

  • Prognosis is excellent in children and poor in those >75 years
  • Overall mortality rate is 30%
  • Factors associated with a poorer prognosis are:
    • Older age
    • Larger haematomas
    • Rapid progression
    • Lower GCS scores
    • Increased intracranial pressure

Subdural Haematoma

Overview

A subdural haematoma (SDH) is a collection of blood in the subdural space (under the dural layer of the meninges and above the arachnoid mater). As the collection of blood increases in volume, the intracranial pressure rises which can lead to complications such as herniation and subsequent neurological compromise.

An SDH is usually due to the rupture of bridging veins in the subdural space and may be acute or chronic.

Epidemiology

  • More common in infants – associated with shaken baby syndrome
    • Due to more fragile bridging veins
  • More common in the elderly – the chronic form is more common here
    • Due to cerebral atrophy and more fragile bridging veins
  • More common in people who suffer with alcohol abuse
    • Due to cerebral atrophy and more fragile bridging veins

Risk Factors

  • Head trauma
  • Increased age – due to cerebral atrophy and fragile bridging veins
  • Infancy – due to fragile bridging veins
  • Alcohol abuse – due to fragile bridging veins
  • Coagulopathy
  • Anticoagulant use

Presentation

Acute subdural haematomas are usually due to high-impact trauma. It is important to appreciate that patients may have other concurrent injuries. Features are:

Chronic subdural haematomas usually present 2-3 weeks after the incident, and symptoms are generally progressive. Features may be:

  • Progressive neurological defects e.g. drowsiness, confusion, personality changes limb weakness, speech difficulties
  • Progressive headaches
  • Anorexia
  • Nausea/vomiting
  • Features of raised intracranial pressure (see Elevated Intracranial Pressure)

Differential Diagnoses

Extradural haematoma

  • Usually history of trauma and patients classically lose consciousness, regain consciousness (lucid interval), then lose consciousness again as the haematoma forms
  • CT head shows hyperdense (bright) convex (lentiform) collection that is limited by suture lines 

Acute subdural haematoma

  • Usually due to high-impact trauma and there are associated brain injuries
  • CT shows a hyperdense (bright) crescenteric collection that is not limited by suture lines
  • Large subdural haematomas may cause midline shifts/herniation

Chronic subdural haematoma

  • Usually seen in patients with fragile bridging veins: elderly people, alcohol abuse, shaken baby syndrome
  • CT shows a hypodense (dark) crescenteric collection that is not limited by suture lines
  • Initially they may be small and not cause symptoms, but subdural haematomas may cause midline shifts/herniation

Subarachnoid haemorrhage

  • Sudden-onset “thunderclap” headache described as the worst headache they have ever had
  • They may have symptoms of meningism – neck stiffness/photophobia

Intraventricular haemorrhage

  • Relatively rare in adults, associated with severe head injuries
  • More common in premature neonates
  • Obstructive hydrocephalus symptoms may emerge and signs of raised intracranial pressure 

Investigations

  • Non-contrast CT head:
    • Acute SDH: hyperdense (bright) crescenteric collection not limited by suture lines
    • Chronic SDH: hypodense (dark) crescenteric collection not limited by suture lines
  • FBC:
    • For thrombocytopenia
  • U&Es:
    • For kidney and electrolyte abnormalities
  • Coagulation screen:
    • For coagulopathy

Management

  • 1st-line: ABCDE and full trauma assessment
  • Treat coagulopathy
  • If small and non-expansile: observe and monitor
  • If intracranial pressure raised (ICP):
    • Raise head to 30° + give analgesia
    • Consider hyperventilation for short periods if urgent ICP reduction needed
    • Other options: hypertonic saline or mannitol
  • If patient confused/neurological defects/severe/midline shift: surgical decompression with burr holes initially then craniotomy and clot removal.
  • If non-accidental injury suspected: refer to senior paediatrician and child protection team

Complications

  • Raised intracranial pressure
  • Seizures
  • Haematoma recurrence
  • Permanent neurological deficits
  • Coma or death

Prognosis

  • Younger patients usually have a better outcome than older patients
  • The prognosis depends on the cause and severity of the haematoma

Subarachnoid Haemorrhage

Overview

A subarachnoid haemorrhage (SAH) describes bleeding into the subarachnoid space and is an emergency. It usually presents as a sudden, severe headache often described as a ‘thunderclap‘ headache. SAH can be spontaneous or traumatic.

Epidemiology

  • Most patients are under 60 years of age
  • Women are affected more than men
  • Around 85% of cases are due to intracranial aneurysms
  • SAH makes up around 5% of strokes

Causes

Causes of spontaneous SAH may be:

Risk Factors

  • Presence of intracranial aneurysm
  • Family history
  • Hypertension
  • Smoking
  • Autosomal dominant polycystic kidney disease
  • Cocaine use
  • Alcohol abuse

Presentation

The classic presentation is a severe sudden-onset “thunderclap” headache in the occipital area. Patients often say it is the worst headache they have ever felt. Other features are:

  • Pain reaches maximal intensity within 1-5 minutes
  • Meningism due to meningeal irritation – photophobia and neck stiffness
  • The headache may be diffuse
  • Nausea and vomiting
  • Hemiparesis
  • Visual field defects
  • Seizures
  • Coma

Some patients may have ‘sentinel headaches‘ due to small leaks from the aneurysm. These present with features similar to SAH but resolve on their own.

It is important to suspect SAH in any patient with a sudden-onset, severe, and unusual headache. It is better to be overly cautious and incorrect rather than missing a SAH.

Differential Diagnoses

Extradural haematoma

  • Usually history of trauma and patients classically lose consciousness, regain consciousness (lucid interval), then lose consciousness again as the haematoma forms
  • CT head shows hyperdense (bright) convex (lentiform) collection that is limited by suture lines 

Acute subdural haematoma

  • Usually due to high-impact trauma and there are associated brain injuries
  • CT shows a hyperdense (bright) crescenteric collection that is not limited by suture lines
  • Large subdural haematomas may cause midline shifts/herniation

Chronic subdural haematoma

  • Usually seen in patients with fragile bridging veins: elderly people, alcohol abuse, shaken baby syndrome
  • CT shows a hypodense (dark) crescenteric collection that is not limited by suture lines
  • Initially they may be small and not cause symptoms, but subdural haematomas may cause midline shifts/herniation

Intraventricular haemorrhage

  • Relatively rare in adults, associated with severe head injuries
  • More common in premature neonates
  • Obstructive hydrocephalus symptoms may emerge and signs of raised intracranial pressure 

Investigations

  • Emergency non-contrast CT head:
    • Shows hyperdense areas in subarachnoid space/basal cisterns
    • If CT shows SAH: immediate referral to neurosurgery
  • If CT done within 6 hours of symptom onset and is normal:
    • New guidelines state not to perform a lumbar puncture
    • Consider an alternate diagnosis and seek specialist advice
  • If CT done after 6 hours of symptom onset and is normal:
    • Perform lumbar puncture at least 12 hours after onset to allow the development of xanthochromia (made from the breakdown of red blood cells)
    • This is to help differentiate between blood due to trauma from the lumbar puncture itself
    • Shows normal/raised opening pressure
  • Immediate referral to neurosurgery once SAH confirmed

Specialist testing

Once a SAH has been confirmed, further investigations can be performed to identify the underlying cause:

  • CT angiography (CTA) – shows aneurysms
    • MR angiography if pregnant/contrast allergy
  • Digital subtraction angiogram (catheter angiogram) – may show an aneurysm
  • ECG: may show widespread T-wave inversion and bradycardia due to raised intracranial pressure

Management

If SAH is confirmed, refer all patients to neurosurgery immediately

  • 1st-line: supportive care, continuous observation and monitoring + oral nimodipine
    • Nimodipine prevents cerebral vasospasm and subsequent ischaemia
  • Consider anticoagulant reversal/correction of coagulopathy

Definitive management: coiling via interventional radiologists  – the preferred method

  • Some patients need craniotomy and clipping by a neurosurgeon
    • Systolic blood pressure should be <180mmHg before coiling/clipping

If hydrocephalus develops: consider CSF drainage via ventriculostomy or lumbar puncture

Patient Advice

  • Patients should stop smoking and be offered help with this
  • Patients should be helped with blood pressure control
  • Patients should avoid straining, sex, lifting etc. for around 4 weeks after being discharged or if they have untreated aneurysms present
  • Patients should be safety-netted on symptoms and should seek help immediately if they return e.g. severe sudden-onset headache, neck stiffness, photophobia, numbness etc. 

Complications

  • Rebleeding – suspect if neurological symptoms worsen
    • Usually occurs within 12 hours
    • Arrange repeat CT scan
  • Hydrocephalus – may be treated with CSF drainage via an external ventricular drain
  • Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and hyponatraemia
  • Vasospasm and cerebral ischaemia – nimodipine prophylaxis is given for this
    • Usually occurs within 7-14 days after onset
  • Seizures
  • Death

Prognosis

  • Overall death rate is around 50%
  • There can be irreversible brain damage
  • Younger patients have a better prognosis
  • Less blood in the subarachnoid space has a better prognosis
  • A more impaired level of consciousness at presentation has a worse prognosis
  • Around half of patients are left with neuropsychiatric problems e.g. mood/memory

Intraparenchymal (Intracerebral) Haemorrhage

Overview

An intraparenchymal haemorrhage (IPH) describes a collection of blood within the brain tissue itself. IPH accounts for up to 20% of strokes.

Risk factors

  • Hypertension – most common cause:
    • Damages cerebral blood vessels which eventually rupture
  • Arteriovenous malformation
  • Aneurysm
  • Tumours
  • Infection

Presentation

Patients with IPH present similarly to those with an ischaemic stroke, hence why a CT is essential in all patients with stroke to rule out IPH.

Investigations

  • CT brain without contrast:
    • Identifies intraparenchymal haemorrhage
    • Shows hyperdense (bright) lesion

Management

Management is mainly supportive under the care of stroke specialists, however, large clots may require surgical treatment (e.g. craniectomy etc).

See Haemorrhagic Stroke: Management for more details.

Intraventricular Haemorrhage

Overview

Intraventricular haemorrhage (IVH) describes bleeding into the ventricular system of the brain, where cerebrospinal fluid (CSF) is produced. It is rare in adults and more commonly seen in neonates within 72 hours of birth.

Management

Treatment is mainly supportive. Shunting is performed if raised intracranial pressure and/or hydrocephalus develop.

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